GPs' management strategies for patients with insomnia: A survey and qualitative interview study

Background: Patients frequently experience sleep problems and present to primary care. However, information is limited regarding the management strategies that GPs employ. Aim: To gain an understanding of current GP management strategies for insomnia. Design and setting: A postal questionnaire survey and qualitative interviews with GPs in the south of England. Method: A postal survey of 296 GPs and qualitative interviews were carried out with 23 of the GPs. Results: The survey response rate was 56% (166/296). GPs look for signs of depression and anxiety in patients and if present treat these first. 'Sleep hygiene' advice is provided by 88% (147/166) of GPs but often seems insufficient and they feel under pressure to prescribe. Benzodiazepines and Z drugs are prescribed, often reluctantly, for short periods, because of known problems with dependence and tolerance. Many GPs prescribe low-dose amitriptyline for insomnia although it is not licensed for this indication. For insomnia 95% (157/166) of survey responders 'ever prescribe' amitriptyline, with 31% (52/166) stating they do so commonly. Most GPs perceived amitriptyline to be effective and a longer-term option for those with ongoing sleep problems. GPs report a lack of knowledge and confidence in the provision and use of psychological therapies, such as cognitive behavioural therapy (CBT), in the management of insomnia. Conclusion: GPs often find 'sleep hygiene' advice is insufficient for managing insomnia and report frequently prescribing medication, including amitriptyline (off licence), which is often based on perceived patient pressure for a prescription. Patients are rarely offered psychological therapies such as CBT for insomnia, despite evidence suggesting its potential effectiveness. ©British Journal of General Practice.